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    Andy Stonehouse, MA

    For physicians and prescribers, finding the right drug for a patient at the right price – and that’s also part of their insurance coverage – can be a delicate balancing act. One false move, or one piece of incorrect data about pricing and coverage, and patients may not be willing to fill that prescription. 

    MGMA partnered with Surescripts for a recent thought leadership panel discussion examining the innovations and benefits provided by EHR formulary information, for both prescribers and patients. 

    The panel, moderated by MGMA Sr. Editor and MGMA Insights podcast host Daniel Williams, included: 

    • Andrew Mellin, MD, MBA, chief medical information officer, Surescripts
    • Jill Helm, Pharm.D, vice-president, solution management, Veradigm
    • Pooja Babbrah, MBA, senior consultant and PBM practice lead, Point-of-Care Partners


    This interview has been edited and condensed. 

    Most EHRs have provided formulary information to prescribers for many years. How does that work?

    Pooja Babbrah: The goal of providing formulary and benefit information to prescribers is really to ensure that the patients are able to get their medications in a timely fashion. We want to make sure providers are prescribing the medications that will actually be covered under a patient’s benefit, without having to go through a lot of approvals. If you look back about two decades, this information was only given to providers in formulary books. Now that providers are using EHRs as an e-prescribing system, this formula and benefit information is incorporated electronically into their workflow, so it’s easy for a provider to determine whether or not that medication will be covered. It can also give them any potential limitations to that coverage: prior authorization, or step therapy, which means that another drug must be tried before the plan will cover that specific information. And sometimes there’s cost information as well. By knowing up front, (patients) don’t get to the pharmacy and find out their medications are not covered, and then they’re waiting a week or two to get the approvals.

    Jill Helm: This formulary information has really been a mainstay for providers, because it provides the information at the point that the physicians are actually creating the prescription. They can see that information passively and in real time, and that’s what’s critical to avoid the re-work – following patients getting to the pharmacy and not having the prescription covered.

    Andrew Mellin: Physicians are bombarded with information all day long, (but this) is designed to be passive, right in the workflow. There’s no extra clicks. Typically, there’s just an icon or some indication of what’s on or off formulary. (Developers) have worked hard to make sure that the physician can just glimpse at this in their workflow and make the most informed decision, with the least amount of additional effort to understand that information.

    Why is this so important? How does it help the patient, the prescriber and the office staff?

    Helm: This information is critically important to be presented at the time the prescription is being created. Not only is that the most efficient way for healthcare to be delivered – the provider can see the formulary information and status, potentially, of alternative medications that could be prescribed – they see all that information up-front, as they’re creating the prescription. That enables them to work very efficiently. It also enables them to make that selection while the patient is in the office with them. If there is an opportunity to change to a different medication that has a more favorable formulary status or is potentially available at a lower cost to the patient, the patient is right there to have that conversation about the choice of medication and therapy that (the doctor) is going to prescribe. It’s also important for the office staff, as it eliminates those callbacks and re-work. That call back into the provider can be very disruptive to the workflow of the office. I’ve seen physicians have to wait upwards of 45 minutes on the phone just to get ahold of the pharmacy.

    Mellin: I heard recently from one of the large PBMs (pharmacy benefit managers) said that when a prescription is written that has an over $50 copay for the patient, there’s a 25% chance that it’s not going to be picked up. The provider has come up with the plan, they’ve worked hard on this, the patient has an expectation set, but if it’s over $50, they’re not going to pick it up. It all starts with getting that information up-front. 

    Formulary has been around for a long time, and like anything in health IT, things grow and evolve over time. Some providers may have tried and looked at this form of (electronic) information in the past and may have felt it’s not as helpful or wasn’t as complete as they would have liked, and they gave up. (More recently), there’s been a huge amount of work that’s been done to improve the quality and availability of this information. 

    Babbrah: Medication adherence is important. Having a clean prescription, where the medication is going to be covered – there’s no prior authorizations involved, or they have been approved ahead of time – just improves that adherence. 

    Hear the entirety of this thought leadership panel discussion in this episode of the MGMA Insights podcast

    How has the process changed or improved for prescribers in the past few years?

    Mellin: To bring that formulary information to the provider, there’s a number of steps along the way. One of the first steps is finding that patient and matching them; every time that patient shows up to the clinic for a visit, the EHR is checking with Surescripts to find their eligibility information and match it to the appropriate formulary. As you can imagine, when we’re doing those matches across 300 million-plus people, those matches can be hard. But we’ve continued to chip away at that. As an example, in 2019, we were able to match 45 million more patients for 45 million more patient encounters than in previous years, due to some improvements we’ve made to our master patient index. The second thing is data quality and mature scripts. We view our role as a facilitator across a network to help our partners make sure that they’re sending complete, accurate, comprehensive information for their partner or about their members – to make sure their fields are populated, things like the prior auth field, and to make sure it represents the current state for the member. Finally, there’s a long tail of smaller payers, or certain payers and regions, that haven’t signed up for the service in the past. We continue to sign them up, and in 2021, you’ll see some additions of major populations on the West Coast and in California. 

    Helm: In partnering with Surescripts, we’ve improved the ability to exchange formulary information efficiently. As you can imagine, these are very large files. And there’s been a lot done from a technical standpoint, with Dell and HP, to improve the efficiencies, but also in terms of standardization. It’s great to work with a partner like Surescripts, where they can bring information from multiple data sources and present it in a unified, concise structure, so it’s easy for the EHR platforms to consume, and for presentation to the physician. 

    Babbraj: A few years ago, we did some research where we had providers and their staff saying that they don’t even look at formulary information because it’s just inaccurate – and we know that’s not the case. So I think that in the marketplace, the providers trust the data, now that it’s more accurate and more timely. That is a huge improvement. 

    Why are you focused on this now?

    Mellin: I think it’s so critical for prescribers to be thinking about cost. We talked to them, and 83% of them told us they consider the patient benefit information in their prescribing decision. Drugs have become more expensive as plans become more complex. We recently looked at 27 million prescriptions (written) to a large retail pharmacy chain. We were able to compare medications that were filled when people were informed by this formulary information versus when they weren’t. We saw that those patients that were informed had a significantly higher rate of pickup. Those are the patients that are getting the medications and have it available in their EHR. 

    Babbrah: In our research and talking to providers, this (cost information) is actually being used. I would say that this has kind of been table stakes for EHR providers for a very long time, so it’s often kind of overlooked as something we need to be focused on. But there are some new enhancements that are coming that are going to be even greater improvements, from a provider and user standpoint. 

    Helm: As more specialty medications come to market that often cost hundreds, if not thousands of dollars, the formulary information really becomes critical. Our physicians depend on that information to assure patient affordability to help ensure medication compliance. And, typically on January 1, having the (updated) formulary information can be of huge value to the physician in knowing what the patient’s current coverage is for a particular medication, because their benefits may have changed. Our physicians are really finding that valuable.

    There is a lot of talk about price transparency. How does formulary complement the new medication price transparency tools?

    Helm: The nice thing about formulary information is that it gives you the status and coverage information across all of the available medications. Price transparency will price a particular prescription for a patient when a particular pharmacy is selected. Formulary information gives you more (about) the cost landscape for that patient or that patient’s drug plan. It enables physicians to make that therapy decision between different medications in the same therapeutic class. They really rely on the formulary information to give them that direction. That’s when price transparency comes in and gives them that very specific patient price. So I see them working together. We start out viewing the formulary information, making the therapy decision, creating the prescription for the patient, and then getting the price transparency information.

    Mellin: We’re seeing some impressive results. When we look at physicians and internal medicine, when they do make a change across all of their medications, they’re saving the patient about $35 per prescription. When you look at blood glucose lowering agents, there’s often a challenge of understanding which is the right drug for the patient. When they (physicians) make the change, they’re saving about $53 per prescription. These are big dollars and significant savings for the patient. 

    Babbrah: We know it’s hard for physicians – they only have a limited amount of time with you, and they don’t want to spend all of their time price shopping for the patient. But there’s recently some industry efforts around bringing that price transparency directly to the consumer, having exactly the same information that a provider would see when they’re actually writing the prescription. Allowing them to say, “OK, normally I go to this pharmacy down the street. Maybe I can get it a little bit cheaper from a different pharmacy.” We’ve also seen CMS come out with some price transparency regulations and rules.  

    What’s left for the industry to do to improve the experience for prescribers and their patients?

    Babbrah: I go back to the standards. The actual formula and benefit transaction, there’s a standard from the National Council for Prescription Drug Programs. Over the past years, the NCPDP members have really put in a lot of works to address some of the issues. There’s going to be some changes coming, and the new standards, one is the decrease in the size of the files – they’re so big, it’s often hard to process them and get them uploaded. There are also some changes in the standard around being able to do indication-based formularies. Then there’s the specialty medications – half of the time they’re covered under the pharmacy benefit, and half the time, they’re under the medical benefit. So with these new changes in the standard, if a PBM knows this information, they can actually alert the physician before they go to try to write the script. 

    Helm: We’re also seeing more detailed information to the provider content within the formulary. We’re seeing changes in step therapy, giving more guidance to prescribers on protocols. And also in the area of pharmacy networks, particularly for specialty medication, which can only be filled at a relatively (small) number of pharmacies in the country. Having that information available at the point of care is critical. 

    Mellin: We’re trying to help our EHR partners get that formulary information up to date, as frequently as possible. Some EHRs are moving to the concept of a real-time formulary, where they are asking us in real time for that formulary information. It often turns out that the information is not incorrect in the Surescripts formulary, but (sometimes) the EHR hasn’t taken that update for months at a time. We are working to make sure their customers can take those updates, at least on a monthly basis, if not more frequently. 

    Any final recommendations?

    Mellin: If you have an on-premise EHR, make sure you’re updating your formulary, because if you’re not doing that, the value of the formulary decreases greatly. Secondly, talk to the people who answer the phone calls, or maybe you have a group of medical assistants that triage ambassador messages, and see how much time your practice is spending on re-work, phone calls back from the pharmacy or messages in the EHR basket. If you’re getting more than you expect, that’s a sign that maybe your physicians aren’t taking advantage of these services as much as they could. Those re-work calls are frustrating for you as a practice, they’re costly and it just makes a bad experience for the patient. Finally, understand what your EHR is doing for the formulary, how it’s being displayed and where it’s showing up. Take an opportunity to help educate your physicians to help them work through any misconceptions they’ve had, so now they don’t look at it. There has been a lot of progress and improvement, and by incorporating it into their decision process, it’s going to make life better for them. 

    Helm: Really engage with your EHR vendor on formulary. Take the time to find out all the information that’s available and the nuances within the presentation of that information. Sometimes, it takes a bit of a refresher to remind practices and providers of the value that the formulary information can bring. Also, partner with your EHR partner to be an active participant in the formulary information process. Work with your vendor on the downloading and consuming of information and how that information is incorporated into patient care. They are really looking for that feedback from the end users to make it an even better process and information source. 

    Babbrah: We often forget that in formulary and benefit, eligibility is really kind of the foundation that’s going to support all these additional transactions. There’s been a lot of improvements in this area, and there’s more coming. If you have not gone back and done that research or looked at when was the last time you updated the files, it’s important to take a step back and read this a bit again.

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    Written By

    Andy Stonehouse, MA

    Andy Stonehouse, MA, is a Colorado-based freelance writer and educator. His professional credits include serving as editor of Employee Benefit News and a variety of financial and insurance publications, in addition to work in the recreation and transportation fields.  


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